NEW!
These are busy days in commissioning land since the publication of the Health and Social Care Bill 2011. I have not made time to calculate its BMI, but at 560 pages, some might have thought this weighty tome a tad light on detail, and so you can expect news, information and conversations about the modernisation of health and care to be signalled elsewhere.
You can follow the Bill's progress through parliament, and even sign up to an e-mail alert to keep up to date with the progress of Bills going through Parliament.
Lots of organisations have had a go at summarising the bill from their own perspective. Check out the commentary and analysis from the King's Fund. You will see that the Faculty of Public Health shares a public health viewpoint, and as you look around you may spot something of a theme suggesting that there are concerns around clinical engagement of GP commissioning consortia with specialist clinical expertise. Take a look at the RCS briefing and coverage by the RCPsych.
Dr Foster's GP Practice Index
GP commissioning consortia can be expected to take out the magnifying glass as they ponder how to reduce costs in practice while improving the quality of care. This index reports on variation in non-elective admissions for conditions treatable in the community, and shows potential cost savings in the areas of ENT infections, flu and pneumonia, COPD, and diabetes complications. GP commissioning may reflect on whether they wish to emulate HM Treasury’s approach to stakeholder engagement.
Budget representations are invited as formal written online representation from any interest group, individual or representative body with the aim of commenting on government policy and/ or suggesting new policy.
By Sue Lacey Bryant, Health Information Specialist
"We like to cluster"
Perhaps the DH has taken to heart the wisdom of Gary Muto, former guru of GAP. Announced as part of the Next steps for reform, with the publication of the Operating Framework in December, PCTs are being "streamlined into clusters, working with GP practices and emerging GP consortia on commissioning as well as reducing running costs".
GP consortia staffing
Consortia have the right to determine their staffing requirements so they will want to keep an eye out for forthcoming HR guidance that is expected to describe a process of 'assignment' of workforce directly to GP consortia. It will also address related issues, including the avoidance of job losses, TUPE arrangements and workforce support for PCT clusters. NHS Employers is a good site to watch.
Developing pathfinder commissioning support services
Clusters will be in place by June and tasked to form a comprehensive support function for all constituent consortia, shaping and redefining the roles of all commissioning support staff who are not directly assigned to consortia.
Meanwhile, one wonders if there could be a market for a customised SatNav, especially for GP leads setting forth to unfamiliar points of the compass as they drive to meetings.
This is well worth a look. It sets out the knowledge, skills and attitudes required by GPs, whatever their past experience or role within a commissioning consortia. At each point, it distinguishes between the respective roles of practice member, practice leader, commissioning leader, and commissioning director.
By Sue Lacey Bryant, Health Information Specialist
Right Care: doing the right things and doing things right
The latest Right Care e-bulletin popped into my inbox mid-month. It's one of but a handful of e-alerts that I open with an expectation of finding something new and of interest. This month it promotes the NHS Atlas of Variation (which commissioners-to-be will want to be aware of) plus the Health Investment Network and The Third Annual Population Value Review. The latter is really a guide to the mysteries of programme budgeting, marginal analysis and various investment analysis tools available to the NHS.
Sign up as you meet the team where Sir Muir Gray is to be seen looking resplendent in a red tie.
Following the NHS Planning cycle
By this time next year will we find that GP consortia leads enter December with bated breath, having already absorbed the NHS planning cycle into their life blood?
The Operating Framework for the NHS in England was published on 15 December 2010. For 2011/12 this is all about transition, seeing the emergence of shadow consortia and pathfinders. Key national priorities include: maintaining performance on key waiting times, continuing to reduce healthcare-associated infections, and reducing emergency readmission rates. The focus is on outcomes. Improving survival rates for cancer patients and new measures of quality for ambulance and A&E services are on the horizon.
The Operating Framework is preceded each winter by the comprehensive Spending Review and HM Treasury works hard to summarise the key announcements into digestible formats. As responsibility for the scrutiny of NHS commissioning moves into local authorities, GP consortia will also want to get this vocabulary under their belt, and understand local implications and any political fallout that ensues.
Incidentally, whenever you are after a quick flavour of opinion and analysis of this sort of major document, you can do worse than check out whether it has been summarised by the health management collection on NHS Evidence.
Primary Care Federations: RCGP Toolkit
Are you finding that you are more interested in providing services than in commissioning them after all? This very practical toolkit offers advice and support on developing a federation to provide services in a collaborative manner.
By Sue Lacey Bryant, Health Information Specialist
Pathfinders
The GP pathfinder consortia has been listed by the Department of Health. These will be the first groups of GP practices to manage their local budgets and commission services for patients directly with other NHS colleagues and local authorities in line with the White Paper. The idea is that these 52 pathfinders will test the new commissioning arrangements and check out that they are working well before more formal arrangements come into place.
The DH has picked on a wide range of different models, covering very different populations (in both size and geography). There will surely be invaluable lessons to be learned before full implementation, should the powers that be have the patience to wait… The King's Fund blog advocates that the progress of the pathfinders will be properly evaluated and they “are a helpful first step in that process if the NHS is indeed to avoid a 'train crash'".
Various support mechanisms are being put in place to support these trendsetters, including the RCGP Centre for Commissioning which has teamed with the NHS Institute for Innovation and Improvement. You can register your interest in this virtual centre committed to equipping GPs, practices and consortia with the skills, competencies and expertise needed to commission patient-focused, safe, high quality healthcare and improve local health outcomes. Watch out for details of competencies and skills frameworks. World class commissioning is dead. Long live…
Feeling it's all rushing past? You can subscribe to an RSS feed bringing you latest additions to NHS Evidence – commissioning
By Sue Lacey Bryant, Health Information Specialist
Factors capable of influencing an increase in GP referral rates to
secondary care
As Health Secretary, Andrew Lansley, advised MPs that there is an "unprecedented level of resources available to the NHS",
Channel 4 News reported on cuts around the country. Warrington PCT is amongst those Trusts who have hit the headlines, in this case by telling GPs that they should not refer patients for non-urgent operations until the next financial year. GP commissioners facing the challenge of ensuring that GP referrals are brought within affordable limits might want to look back 18 months to the
BMA's short briefing on this highly complex area.
No prizes for spotting that it is likely to be a unique balance and combination of key factors that influence fluctuations in referral rate and variation between PCTs, practices and GPs themselves. Local practice in primary care and secondary care, stirred up with patient expectations, are all part of an expensive mix. Chances are that these variations can only be deciphered by local analysis, with a good look at referrals by specialty rather than simply focusing on figures for average GP referral to hospital.
Introducing the NICE referral advice database
NICE has pulled together, into one database, the details of referral advice previously tucked away in its published guidance. Covering conditions such as suspected cancer, lower back pain and psoriasis, the entries highlight recommendations that clearly show potential benefit from secondary care or specialist services and, by implication, those where patients would not benefit from these services. Perhaps the latter is a tad trickier, given that the "absence of evidence is not evidence of absence"? Nevertheless, you will get the drift - and this is another detailed resource which those GPs wearing a commissioning hat will want to see impinging on the detailed work going on backstage in their local PCT or PBC.
By Sue Lacey Bryant, Health Information Specialist
From patient notes to pound notes
Maybe you are already plugged into working with your local hospital (and community services) on system and service redesign? If so, you might want to get a handle on the payment structure. Take a look at A simple guide to Payment by Results by the Department of Health (DH). At 70 pages, this is in fact a readable introduction to Payment by Results for those new to it.
Regional Health Profiles
Designed to assist local service planning, the 2010 Regional Health Profiles may give you a new perspective on the challenges facing commissioners. The profiles highlight considerable variation in health across the country. Using a set of key indicators compared to national and regional averages, the profiles present a snapshot of health for each local authority area in England and can help to identify priorities for health improvement.
Too far, too fast?
Questioning the Coalition's decision to launch into a fundamental reorganisation of the NHS just as the service faces the biggest financial challenge in its history, The King's Fund response to the white paper was to ask for a rethink on the speed and scale of reform. Supporting the principles of giving GPs a stronger role in commissioning services alongside strengthening the role of local authorities, and extending patient choice, The King's Fund suggests a more measured approach.
Ready and willing?
With the aim of empowering "pioneering groups of GP practices that want to press ahead with commissioning care for patients", the pathfinder programme has been launched to support groups of practices ready and willing to make faster progress, under existing arrangements. Candidates need to be able to demonstrate GP leadership and support plus Local Authority engagement or an ability to contribute to the delivery of the local QIPP (Quality, Innovation, Prevention and Productivity) agenda.
By Sue Lacey Bryant, Health Information Specialist
GP commissioning: what can we learn from previous commissioning models?
This short and crisp briefing from the King's Fund packages the headlines from key reports on different commissioning models tried in the UK that you wish you'd read (but perhaps didn't?). Skip through this to be in the know on GP fundholding, total purchasing and practice-based commissioning. It spells out lessons learned across the pond too, including: the high transaction costs that fund holding can entail, the real financial risk that needs to be managed, and that groups should be accountable for quality and patient experience, not just cost. I note that "GP budget holders need access to strong management support and information to ensure that they use their resources effectively".
The art of the profitable?
GP commissioners will surely be signing up to Davis Tansley's dictum, "Don't confuse the art of the possible with the art of the profitable". For example, moving care closer to home brings benefits, yet the final report from the NPC R&D centre indicated that "wider impacts on health system quality, capacity and cost" merited close scrutiny. Hence, tools like RONI, a ready-made Excel chart shared through NHS networks, are at the very least a useful reminder of the need to calculate the service, implementation and benefits (eg changes in admissions and length of stay) of improvement and innovation projects.
By Sue Lacey Bryant, Health Information Specialist
Benchmarking, benchmarking, benchmarking
GP commissioners want to be up to date with best practice and innovation, not just in the UK but worldwide so that they can benchmark existing services and influence service redesign.
Credible business intelligence is surely going to be a key ingredient for successful consortia, and there are resources that will help; starting off with NHS Comparators.
NHS Comparators
Freely available, Comparators presents a ‘standard view’ of data on around 200 comparators and looks at activity and costs. The idea is that this stuff should not be just the specialist turf of NHS data kings and queens, but readily accessible so that you can get an overview of care pathways, spot where improvements might be made and then round out the picture with locally held information.
Signposting benchmarking tools
Find a helpful listing of benchmarking tools in the wiki commissioning handbook compiled by NHS librarians. This introduces what commissioning involves and the stages of the commissioning cycle, signposting key aspects on which commissioners may need information.
NICE work?
NICE commissioning guides are designed to help those involved in commissioning ensure that services are designed and delivered in accordance with best evidence. Along with advice on aspects of clinical care, these present ready-made spreadsheets for calculating the cost impact of different service delivery options.
By Sue Lacey Bryant, Health Information Specialist
They say "it helps to talk"…
The Doctors.net.uk commissioning health forum was set up to create an opportunity for a lively exchange of views about the emerging opportunities and responsibilities for GP consortia. Contributors can air their views, pose questions and, occasionally, vent steam.
NHS Networks is also busy trying to connect people and ideas. A couple of new networks that might encourage you to sign up are the GP Consortia Network and Health Investment Network. Both seem pretty slow to take off. Still, it has been a long and busy summer for consortia leads, with no shortage of e-mails popping into their inbox.
Health economics
For those looking forward to taking hold of the purse strings, a new focus on economic analysis is going to be the name of the game.
Yorkshire and Humber Public Health Observatory (YHPHO) take a lead on health economics, with a focus on programme budgeting, market management and more. You may be interested in doing a quick SPOT check yourself, downloading the Spend and Outcome Factsheet for your own PCT or using the Spend and Outcome Tool (which allows you to view the data in more detail). This is work led by YHPHO, and commissioned from The Association of Public Health Observatories (APHO) by the Department of Health.
By Sue Lacey Bryant, Health Information Specialist
King's Fund report on referral management
Perhaps emerging consortia will choose to cut their teeth on the vexed issue of demand management? Given that GPs make more than 9 million referrals to hospitals each year for elective care, and that this triggers health service spending upward of Ј15 million, GP leaders wanting to grasp this nettle will view the King's Fund report on referral management as obligatory reading.
Members of the GPC have had a busy summer. September sees the publication of the committee’s initial observations on GP consortia commissioning. Suggesting that it may be tricky for consortia with populations of less than 500,000 to manage the financial risk or achieve economies of scale, the underlying theme is that “effective commissioning is effective general practice”.
Meanwhile, in offering a legal overview and guidance, the GPC is at pains to be clear that “no definite legal requirements and/or processes are as yet known, nor have they been agreed or implemented”. This is a short, readable introduction to the legal issues of the commissioning proposals that GPs may have to consider pending the outcome of the consultation on the White Paper. The advice has a cautionary tone, best summarised in the words of my old dad, “nothing precipitate”.
By Sue Lacey Bryant, Health Information Specialist
BMA GPC statement
The principles of GP commissioning, a five page statement from the GPC, will rest at the top of many reading piles as fledgling consortia begin to form. Do we hold these truths to be self-evident? we may ask as we skip through.
In fact, the NHS Confederation has already challenged the legality and wisdom of one of the "fundamental principles" put forward by the BMA in its first statement on GP commissioning - namely that "wherever possible, consortia should ensure that NHS organisations are the providers of choice".
Nigel Edwards, Acting CEO of the NHS Confederation, commented, "As commissioners, GP consortia will have a responsibility to purchase the best quality care for patients while also providing value for the taxpayer". He also adds, "For-profit and not-for-profit firms have played an important role in providing a range of services, including mental health and community services, to the NHS for many years".
Another truth, universally acknowledged it appears, is that "GPs like to be loved". So says Richard Vautrey, Deputy Chair of the BMA GPs Committee, commenting on the implications of an analysis of spend by PbC collaboratives from 33 PCTs. The HSJ found that 83% overspent their indicative commissioning budget in 2009-10, showing, in Vautrey's view, that there are tough times for fledgling consortia.
By Sue Lacey Bryant, Health Information Specialist
Getting involved or sitting on the sidelines?
"How many of the new GP consortia will be led by women?" I mused idly whilst listening to an item on Radio 4. For in a speciality that charts such a success story for women, commissioning will surely bring fresh opportunities for those who want them.
Meanwhile, "Two thirds of the nation's employees, both male and female, agree they would rather work for a man than a woman", reads a recent press release – a welcome distraction from the Four Horsemen who ride the news. Mind, for NHS managers listening as they drive to work, the operative phrase in that announcement sentence is already "would rather work…"
Still, that doesn’t change the broader point about the shape of the medical workforce. Right now, Women doctors: making a difference reports that 41% of the workforce is female - and this figure is rising, as women account for 57% of admissions to medical school. Plus, as many as 49% of female GPs work part-time.
So, the Medical Women’s Federation (MWF) put out a clarion call in its response to the White paper. "Women doctors, who will soon make up the majority of the workforce, will have to get involved, in leadership and other roles - it will not be an option to sit on the sidelines". Clarissa Fabre, President of MWF, warns that "40% of the workforce are now salaried or locum, and there is a substantial risk that general practice will become a salaried service, run by a few entrepreneurial GPs and private companies".
Another argument runs that salaried GPs may be better suited to roles in GP consortia than partners.
Discuss…
By Sue Lacey Bryant, Health Information Specialist
Giving GPs budgets for commissioning – Nuffield Trust Briefing paper
Look at the latest briefing from the Nuffield which synthesises the reflections of key national organisations, including the RCGP. My reading is that while they recognise the challenge of taking GP commissioning from a minority sport, they also believe that handing real budgets to GP commissioning groups has the potential to help improve patient care.
Coalition Consultation on proposals for the NHS
Commissioning for patients, the consultation document on the implementation of government proposals for Liberating the NHS, is now out. Due to close on 11 October 2010, this consultation is just one element of wider engagement on the White Paper. The Coalition is seeking views on clinical engagement, patient involvement and, not least, on the form of relationship needed between GP consortia and the NHS Commissioning Board if the new system is to commission efficiently and really deliver improved outcomes on budget.
Increasing democratic legitimacy in health may not be a phrase that readily trips off your tongue of a Saturday night. Then again, is it so fanciful to picture leaders of the new consortia huddled around the patio heater as they ponder how best to get local taxpayers on board with the monumental decisions that lie ahead?
By Sue Lacey Bryant, Health Information Specialist
With the publication of Equity and Excellence, structural reform is now the order of the day across the NHS.
The Draft Structural Reform Plan from the DH (July 2010) sets out the timetable. See for yourself the milestones for revolutionalising NHS accountability through the formation of the Commissioning Board and GP commissioning consortia.
With GPs charged with full responsibility for commissioning from April 2013, the next three years will surely whizz past. Wasn’t it only in 2007 that the machinery of World Class Commissioning was set in train? It remains to be seen, of course, whether GP commissioners will pack the best of WCC as they set out on their own journey.
One sure thing is that the importance of robust data will rise to the fore as GPs take the driving seat. For those to whom this stuff is new, both the Commissioning specialist collection from NHS Evidence and the NHS Information Centre with its depiction of the commissioning cycle are worth a look.
The language of change is best taken with a pinch of salt, of course. Will deep dive™ brainstorming put 'hitting the ground running' onto the back-burner, we ask? Either way, GP commissioners newly responsible for driving out inefficiency may want to check out Helen Bevan's work on change management.
By Sue Lacey Bryant, Health Information Specialist